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2018-19 ECEAP Prescreen & Application (Combined form)Return to: XXXX

1. Child Information School year applying for:

Legal First Name Middle Name Legal Last Name

Child’s birth date ____/_____/________ Nickname Gender

Is this child on an Individualized Education Program (IEP)? Yes No

If no, do you have any concerns about this child’s development? Yes No

Is this child in official foster care? This means there is a caregiver authorization

from a state or tribe that says this is a foster care placement. Yes No

Is this child’s family currently receiving Child Protective Services (CPS)

or similar Indian Child Welfare (ICW) services? Yes No

Is this child’s family currently receiving Family Assessment Response (FAR)? Yes No

Is this child homeless?

This means no fixed, regular, and adequate nighttime residence. Yes No

If yes, does this child live with a parent or consistent guardian? Yes No

Is this child living with a guardian, who is not their parent or foster parent,

who receives a state, tribal, or SSI payment on behalf of the child? Yes No

This child speaks (select only one): Only English Mostly English, and some of another home language Some English, but mostly another home language English and another language at age level (bilingual) Only a home language other than English

Child’s first language Child’s second language

ECEAP Combined Prescreen & Application Revised March 2018 Department of Child, Youth, & Family Services of 9

Is this child Hispanic/Latino? Yes No

If yes, check all that apply:

Argentinian Bolivian Chilean Colombian Costa Rican Cuban Dominican Ecuatorian (Ecuadorian)

Guatemalan Honduran Mexican or Mexican-American

(Chicano) Nicaraguan Panamanian Peruvian Puerto Rican

Salvadoran Spanish Uruguayan Venezuelan Latin American Other Hispanic or Latino

(describe)____________________

What race(s) do you consider this child? (Check all that apply)

White

Black or African American

Alaska Native Aleut (Unangan) Alutiiq Athabaskan Eskimo (Inupiaq or Yupik) Eyak Haida Tlingit Tsimshian Other Alaska Native

(describe)_______________

American Indian Chehalis Chinook Colville Cowlitz Duwamish Hoh Jamestown Kalispel Kikiallus Lower Elwha Lummi Makah Muckleshoot Nisqually Nooksack Port Gamble Klallam Puyallup Quileute

Quinault Samish Sauk-Suiattle Shoalwater Skokomish Snohomish Snoqualmie Snoqualmoo Spokane Squaxin Island Steilacoom Stillaguamish Suquamish Swinomish Tulalip Upper Skagit Yakama Other American Indian

(describe)_______________

Asian Asian Indian Bangladeshi Bhutanese Burmese Cambodian/Kampuchean Chinese Filipino Hmong Indonesian Japanese Korean Laotian Madagascar Malayan

Maldivian Mongolian Nepali Pakistani Singaporean Sri Lankan Taiwanese Thai Vietnamese Other Asian

(describe)_______________

Native Hawaiian or Other Pacific Islander

Fijian Guamanian Kosraean Mariana Islander Marshall Islander Melanesian Micronesian Native Hawaiian Palauan Papua New Guinean Ponapean (Pohnpeian) Samoan Solomon Islander Tahitian Tarawa Islander Tokelauan Tongan Trukese (Chuukese) Vanuatuan/New Hebrides Yapese Other Pacific Islander

(describe)_______________


2. Household MembersPlease list everyone living in the household who may be counted in family size. For families temporarily living with relatives or others, do not list the hosts. For families with two households when there is joint custody with no primary parent and no child support

Enter the household members for both households in the graph below. Mark members of the second household. Then, answer the questions about financial support and relationships.

Staff will use this information to calculate family size to determine federal poverty level.

Skip these two questions ifECEAP child is in foster care or living with a guardian who receives a payment for care.

First Name Last Name BirthdateRelationship

to ECEAP Child

Does the ECEAP child’s parent or guardian financially support this person?* See note below for people age 19 or older.

Is this person related to the ECEAP child’s parent/guardian by blood, marriage, or adoption?

ECEAP Child: ECEAP Child Yes Yes

Parent/guardian: Yes Yes

*Answer No for a person age 19 or older who has earned or unearned income that covers more than half of their expenses. Answer Yes if the ECEAP child’s parents pay more than half of expenses.


For staff use only:Family size for FPL chart _____

For children in foster care or kinship care with a payment, count family size as 1.For all others, count people with Yes for both questions above.

3. Family Contact Information Do you need an interpreter to communicate with English speakers? Yes No

If yes, what language(s) do you speak?

Physical Street Address Apt # City Zip

Mailing Address (if different) City Zip

Email

Phone Alternate Phone

4. Child lives with: One parent/guardian (Name) Skip to section 5.

Two parents/guardians in same household (Names)

Skip to section 5.

Two parents/guardians in two households If this is checked, answer these questions to determine which parents’ income is counted for ECEAP eligibility.

Does one household have primary legal custody? Yes No

If yes, which parent has primary custody? Spouse of this parent, if any: Skip to section 5.

If no, does one parent receive child support payments from the other household? Yes No

If yes, which parent receives the child support payments? Spouse of this parent, if any: Skip to section 5.

If no, ECEAP will count the income from the legal parent/guardian for each household. Do not include their spouses. Enter the legal parents’ names here:

Household 1 Household 2

Contact Info for Household 2:

Physical Street Address Apt # City Zip

Mailing Address (if different) City Zip

Email

Phone Alternate Phone


5. Parent Employment, Training, and Other Activities

Answer the following questions for each parent/guardian named in question #4

Parent/Guardian #1Name ______________

Parent/Guardian #2Name _____________

Is this parent/guardian employed? Yes No Yes No

a. If yes, enter number of hours per week in paid work plus work-related travel.

b. If yes, enter employer name and phone or email.

Is this parent/guardian enrolled and attending school or job training? Yes No Yes No

a. If yes, enter the total number of hours per week when school is in session. Include class time, up to 10 hours of study time, and travel time.

b. If yes, enter name of school or training organization.

c. If yes, enter goal or major.

Is this parent/guardian in an approved WorkFirst activity other than employment, education or job training mentioned above? Yes No Yes No

a. If yes, describe activity.

b. If yes, enter number of hours per week in approved activity and related travel.

Is family approved for child care through CPS, FAR, or similar tribal funds? Yes No Yes No

a. If yes, enter number of approved hours per week.

6. How did you find out about ECEAP? DEL website Community event Flyer ECEAP employee Word of mouth

Caseworker Media Community agency - Name of agency:

Other - Describe other:

7. Survey for statewide planningIf you could choose the length of day for your child’s preschool, which is best for your child and family?Please note, these options may not all be available in your community this year.

Part Day – about three hours, three or four days a week.

Full School Day – about six hours, four or five days a week.

Extended Day – available all day, all year, like a child care center.

8. Household SituationDoes your household receive subsidized housing, such as a housing voucher or cash assistance for housing? Yes No

Does your household currently receive a Working Connections child care subsidy for this child? Yes No


9. Income Received by Child’s Parent(s) or Guardian(s)

For children in foster or kinship care:

If this child is in foster care or living with a guardian who receives a payment for the child, fill in this box & skip to section 10.

Monthly grant or payment amount $ # of children covered by this grant amount

Case # or Client ID # Payment source (circle): DSHS SSI Tribe Other

Did you receive income during the last calendar year or during the previous 12 months? Yes NoIf no, describe reason family does not have income:

Enter all family income for one year in the chart below.

Select either: Previous calendar year Previous 12 months

Person(s) with

Income

Type Weekly Amount

# of Weeks

Received

Monthly Amount

# of Months

Received

Annual Amount

W-2 $W-2 $Tax return (1040) or IRS transcript $Tax return (1040) or IRS transcript $Pay stubs for 12 months $Pay stubs for 12 months $Child Support received, if required by a child support order

$ $

Disability income, including SSI $Military Leave & Earnings Statement (LES). Count all pay and allowances except BAH, BAS, FSH, and HFP/IDP.

$

Self-employment net incomeSocial Security or other retirement benefits

$ $

TANF cash assistance $ $Child-only TANF or foster care grant for non-ECEAP child

$ $

Unemployment $ $Workers Compensation (L&I) $Tribal income (taxable) $Other income not classified above $ $

$Subtract Child support paid to another

household, if required by a legally-binding child support order

$ -$

TOTAL $

Do you still receive the income above? Yes No If yes, skip to section 10.

If no, and your circumstances have recently changed, please explain:

Divorce or separation Loss of job Job change Loss of wage earner Loss of benefits Other (explain)

What is your monthly income? $_________________ For which month?


10. Previous EnrollmentThis child was previously enrolled in:

Head Start at your agency Head Start with a different agency Migrant/Seasonal Head Start

anywhere in Washington

Early Head Start Any birth-to-three home visiting program ESIT - Early Support for Infants and Toddler

11. IEP or Suspected Delay This child has an Individualized Education Program (IEP). This child has a suspected developmental delay or disability.

If this child has an IEP check all categories of the IEP. If not, skip to section 12.

Autism Intellectual disability Specific learning disability

Deaf-blindness Multiple disabilities Speech or language impairment

Developmental delay Orthopedic impairment Traumatic brain injury

Emotional disturbance Other health impairment Visual impairment

Hearing impairment

IEP Start Date ________________ IEP End Date ___________________

What school district issued this child’s IEP?

Is a school district special education preschool available for this child? Yes No

12. Has this child been asked to leave a child care or preschool because of behavior issues? Yes No ECEAP serves children with behavior issues. Checking yes will not exclude your child.

13. Additional Questions We use this information to choose the children who most need ECEAP. All responses will be kept confidential.

Has this child been homeless within the last 12 months? Yes No

Does this child have a parent who is developmentally or physically disabled? Yes No

Does this child have a parent currently on active duty in the U.S. Military? Yes No

Does this child have a parent currently a member of a National Guard unit or a Military Reserve unit? Yes No

Does this child have a parent who is currently or was recently deployed to a combat zone? Yes No

Does this child have a parent who is incarcerated in jail, prison or a detention center? Yes No

Does this child have a parent experiencing mental health issues (including maternal depression)? Yes No

Does this child have a parent who was under age 18 when this child was born? Yes No

Does this child have a parent who is a migrant worker? Yes No

Has this child’s family received services from Child Protective Services (CPS) or similar Indian Child Welfare (ICW)

services in the past? Yes No

Has this child’s family ever experienced domestic violence? Yes No

Does this child’s family struggle with substance abuse issues? Yes No

Does this family have a support system outside of the household? Yes No

ECEAP received a professional referral for this family. Yes No

If yes, which agency made the referral?


14. Parent Education Level: Check all that apply (√)

Highest level of education Parent/Guardian 1Name_________________

Parent/Guardian 2Name_________________

6th grade or less

7th to 12th grade, no diploma or GED

High school diploma or GED

Some college

Professional certificate (includes vocational schools)

Associate degree

Bachelor’s degree

Master’s degree or doctorate

15. Health Information Please attach a copy of the child’s immunization record

Does this child have a chronic health condition such as diabetes, asthma, seizures, etc.? Yes No

If yes, please describe

Did this child weigh less than 5.5 pounds when they were born? Yes No Unknown

Does this child have medical insurance or coverage? Yes No Unknown

Washington Apple Health for Kids/ Provider One Services Card

Military Dental Coverage Private Dental Insurance

Tribal Coverage

Does this child have a regular doctor or medical clinic? Yes No Unknown

Name of clinic or provider

Phone (optional)

Name of medical professional

Did this child have a well-child exam within the last 12 months? Yes No Unknown

Date of last well-child exam before applying for ECEAP / / Date Unknown

Does this child have dental insurance or coverage? Yes No Unknown

Washington Apple Health for Kids/ Provider One Services Card

Military Dental Coverage Private Dental Insurance

ABCD (not available in all counties) Tribal Coverage


Does this child have a regular dentist or dental clinic? Yes No Unknown

Name of clinic or provider

Phone (optional)

Name of dental professional

Did this child have a dental screening within the last 6 months? Yes No Unknown

Date of last dental screening before applying for ECEAP / / Date Unknown

Signature of Parent/GuardianI certify that the information on this form is true and correct. I understand that, if I knowingly provide false information, my child could be disqualified from ECEAP and I may have to reimburse the amount spent on my child’s ECEAP services ($780 or more per month).

I understand that information in this application may be combined with information about other ECEAP children and used for research studies, such as determining if participating in ECEAP helps children later in life. The identities of children and families would be removed before analyzing information for research.

I understand that information in this application may be reported to other state agencies. For example, individual child enrollment dates could be used to determine if state dollars spent on ECEAP may be used as “federal match” to allow Washington to receive more federal funds to serve families.

Print name

Signature Date

Signature of ECEAP Staff Member who verified eligibility

I certify that, to the best of my knowledge, the information on this form is true and correct. I viewed and verified documentation establishing this child’s eligibility for ECEAP. I understand that ECEAP Performance Standards require that I notify the Department of Child, Youth, and Families (formerly Department of Early Learning) if I suspect any fraudulent use of ECEAP funds including, but not limited to, an employee intentionally entering deceptive or false information into ELMS regarding:

o Child eligibility criteria.o Children’s actual start dates and last days in class.o Class start or end dates.o Services that were not actually provided. o A family providing false information in order to enroll in ECEAP.

Print name

Signature Date


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